At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge, and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.
Job Summary Administers the Clinical Documentation Improvement (CDI) program across multiple sites to support accurate and complete clinical documentation, quality outcomes, severity capture, acuity, and risk of mortality reporting. Utilizes project management expertise, clinical knowledge, and understanding of coded data and documentation requirements to improve patient record integrity and reimbursement accuracy. Collaborates closely with coding professionals, physicians, and multidisciplinary teams to ensure documentation compliance and effectiveness. Partners with hospital, Area, District, and Support Center leadership to achieve program goals and operational objectives.
Experience - Minimum of three (3) to four (4) years of clinical experience required
- Examples include inpatient care, clinical documentation improvement, and/or case management review
- Prior Clinical Documentation Improvement (CDI) experience required
Essential Functions - Implement and provide oversight for a multi-site Clinical Documentation Improvement program in a standardized and organized manner
- Mentor and train new Clinical Documentation Improvement staff
- Establish and maintain effective working relationships with hospital, Area, District, and Support Center leadership and staff
- Facilitate appropriate clinical documentation to support accurate diagnosis capture and reimbursement
- Review primary and secondary diagnoses, complications, Present on Admission (POA) indicators, and Hospital Acquired Conditions (HACs) to ensure documentation specificity and completeness
- Initiate provider clarification and query processes when documentation improvement opportunities are identified
- Collaborate with coding staff and physicians to identify diagnoses impacting severity of illness, risk adjustment, and quality indicators
- Serve as a subject matter expert in medical record review to support accurate diagnosis capture and coding across all payer types, including CMS, Medicare Advantage, and RAC reviews
- Support development of CDI workflows, educational initiatives, and documentation improvement programs for internal stakeholders
- Collaborate routinely with Case Management leadership, HIM staff, and clinical teams through coding calls, meetings, and site visits
- Submit relevant documentation and coding information through established CDI software systems and communication channels
- Conduct quality assurance reviews of CDI processes and recommend corrective actions as appropriate
- Compile and present reports to Physician Advisors, Medical Directors, committees, and executive leadership
- Provide CDI education regarding documentation improvement opportunities, DRG optimization, and coding accuracy to clinical and operational leaders
- Conduct data analysis and root cause reviews; communicate findings and recommendations to leadership and medical staff
- Lead provider query processes and maintain tracking and reporting of verbal and written queries
- Participate in committees, workgroups, and organizational initiatives as assigned
Knowledge, Skills, and Abilities - Expert interpersonal, verbal, written, and presentation skills with the ability to communicate effectively with physicians, executive leadership, and multidisciplinary teams
- Knowledge of Adult Learning Theory and educational methodologies
- Strong understanding of coding classification systems including ICD-10-CM, MS-DRG, APR-DRG, and HCC methodologies preferred
- Ability to combine clinical expertise and business acumen to drive operational improvements and achieve organizational goals
- Experience leading projects, streamlining workflows, and supporting process improvement initiatives
- Strong analytical and problem-solving skills with the ability to manage multiple priorities and deadlines
- Knowledge of healthcare revenue cycle operations and reimbursement practices
- Proficient computer skills including Microsoft Office applications, spreadsheets, and presentation software
- Understanding of healthcare policy trends, regulatory requirements, and operational practices within LTACH environments
- Ability and willingness to travel to designated company facilities within a 100-mile radius of primary residence as needed for operational or business purposes
QualificationsEducation - Associate or Bachelor's degree from an accredited school of Nursing, Health Information Management, Medicine, or related healthcare field required
- Master's degree preferred
Licenses/Certifications - Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification required within two (2) years of hire into the role
Experience - Minimum of three (3) to four (4) years of clinical experience required
- Examples include inpatient care, clinical documentation improvement, and/or case management review
- Prior Clinical Documentation Improvement (CDI) experience required
